Visscher, J.G., Grond, A.J., Botke, G., and van der Waal, I. (1996). Results of radiotherapy for squamous cell carcinoma of the vermilion border of the lower lip: a retrospective analysis of 108 patients. Radiother. Oncol. 39: 9–14. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8735488.21 de Visscher, J.G., van den Elsaker, K., Grond, A.J. et al. (1998). Surgical treatment of squamous cell carcinoma of the lower lip: evaluation of long‐term results and prognostic factors – a retrospective analysis of 184 patients. J. Oral Maxillofac. Surg. 56: 814–820. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9663570.
SECTION 2 Oropharynx
Liana Puscas
CASE 7
Raymond Chai
History of Present Illness
A 62‐year‐old Caucasian male is seen in the office with a 2‐month history of a palpable left neck mass.
Question: What additional questions would you want to ask?
Is it painful? Patient denies.
Is it tender to the touch? Patient denies.
Is it growing? Patient denies.
Any trouble swallowing? Patient denies.
Any voice changes? Patient denies.
Any throat pain? Patient denies.
Any ear pain? Patient denies. Base of tongue/tonsil tumors may produce referred ear pain.
Any skin changes over the mass? No. Erythema or induration could indicate extranodal extension of a malignancy or an infectious etiology (e.g., scrofula).
Has he received any treatment for this? Yes. He has undergone two rounds of antibiotic therapy and steroids without decrease in the size of the mass.
Past Medical History
Hypercholesterolemia, hypertension.
Past Surgical History
Appendectomy and tonsillectomy as a child.
Medications
Atorvastatin, lisinopril.
No known drug allergies.
Social History
Tobacco use? Patient denies.
Alcohol use? The patient has a glass of wine with dinner on a regular basis.
Physical Examination
Well‐developed male in no distress. Voice strong.
Skin: no suspicious lesions.
Oral cavity examination shows teeth in good condition. No lesions seen or palpated.
Oropharynx: tonsils surgically absent; no lesions palpated in the base of tongue but exam limited due to gag reflex.
Neck exam: salivary gland exam normal. He has a 3 cm left level IIA neck mass that is mobile on palpation.
Cranial nerves II–XII intact.
Flexible laryngoscopy is performed without obvious lesions seen of the upper aerodigestive tract. The true vocal folds move well.
Management
Question: Which of the following would be appropriate next steps in the evaluation and management of this patient?
Fine needle aspiration biopsy: yes/no. This is probably the best next step as it will likely yield a diagnosis. The use of ultrasound guidance is often helpful as these lesions may have a significant cystic component.
Excisional biopsy of the neck mass: yes/no. Open surgical biopsies should be avoided, when possible, due to the concern for tumor seeding and disruption of surgical tissue planes. In instances where the clinical presentation suggests lymphoma and a fine needle aspiration shows lymphoid tissue, without evidence of carcinoma, an excisional biopsy can be considered. In these instances, the surgeon should discuss the option of sending the mass for a frozen section and if cancer is found intra‐operatively, a completion neck dissection and endoscopy should be performed.
Computed tomography (CT) of the neck with IV contrast: yes/no. This is a potential next step as this will allow for evaluation of the neck and the upper aerodigestive tract.
Neck ultrasound: yes/no. This is a potential next step as this will allow for evaluation of the neck mass and may be used to confirm correct needle placement during the FNA. Newer techniques have also allowed for transcervical evaluation of the oropharynx for potential primary lesions.
Magnetic resonance imaging (MRI) of the neck: yes/no. This is a potential next step as this will allow for evaluation of the neck and the upper aerodigestive tract.
Positron emission tomography (PET)/CT neck: yes/no. This is a potential next step as this will allow for evaluation of the neck and the upper aerodigestive tract as well as provide assessment of metastatic disease. It is important to note that typically a biopsy should demonstrate malignancy before obtaining a PET/CT.
Question: What additional testing may be performed of an FNA specimen to aid in diagnosis of an unknown primary?
Answer: Assessment for p16 and EBER. Molecular diagnostic testing should be performed to assist in identifying potential occult primary sites. Per the AJCC 8th Edition guidelines, p16 should be performed as a surrogate for human papillomavirus (HPV)‐associated oropharyngeal carcinoma. Likewise, Epstein–Barr virus‐encoded RNA (EBER) should be performed to evaluate for an occult nasopharyngeal primary carcinoma.
Question: What threshold for p16 immunohistochemistry (IHC) is typically used to define p16 positive disease?
Answer: 70%. Per the College of American Pathologists guidelines for HPV testing in head and neck carcinoma, pathologists should report p16 IHC positivity as a surrogate for HPV when there is at least 70% nuclear and cytoplasmic expression with at least moderate to strong intensity.
Fine needle aspiration is performed in the office under ultrasound guidance. The final pathology reveals nonkeratinizing squamous cell carcinoma (SCC) that is p16+.
Question: What imaging
